🔎 Peace Healthcare At Lions Center
Inspection Results
Inspection Overview
Peace Healthcare At Lions Center has been cited for a total of 114 deficiencies since we began saving each survey.
In Maryland, the average facility has **52.01 deficiencies** in our database. This profile shows the longer-term view.
Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.
Understanding Deficiency Severity (A-L Scale)
The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**
| Severity (Harm) | Scope (Widespread?) | Code Range |
|---|---|---|
| No Actual Harm | Isolated to Pattern | A - C |
| No Actual Harm | Widespread | D - F |
| **Actual Harm** | Isolated | G |
| **Actual Harm** | Pattern | H |
| **Actual Harm** | Widespread | I |
| **Immediate Jeopardy** | Isolated | J |
| **Immediate Jeopardy** | Pattern | K |
| **Immediate Jeopardy** | Widespread | L |
Detailed Deficiency List (Most Recent First)
Scope/Severity: D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Scope/Severity: D
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Scope/Severity: D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Scope/Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Scope/Severity: D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Scope/Severity: D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Scope/Severity: D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Scope/Severity: D
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Scope/Severity: D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity: D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity: D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: D
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Scope/Severity: F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Scope/Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Scope/Severity: D
Reasonably accommodate the needs and preferences of each resident.
Scope/Severity: D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: D
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Scope/Severity: E
Ensure each resident receives an accurate assessment.
Scope/Severity: E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Scope/Severity: D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: E
Provide safe, appropriate pain management for a resident who requires such services.
Scope/Severity: D
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Scope/Severity: E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity: D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Scope/Severity: C
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies.
Scope/Severity: D
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Scope/Severity: E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Scope/Severity: D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Scope/Severity: D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: D
Respond appropriately to all alleged violations.
Scope/Severity: D
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Scope/Severity: E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Scope/Severity: D
Prepare residents for a safe transfer or discharge from the nursing home.
Scope/Severity: E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Scope/Severity: E
Ensure each resident receives an accurate assessment.
Scope/Severity: D
Ensure a qualified health professional conducts resident assessments.
Scope/Severity: D
PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity: E
Provide activities to meet all resident's needs.
Scope/Severity: G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Scope/Severity: E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Scope/Severity: D
Observe each nurse aide's job performance and give regular training.
Scope/Severity: D
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Scope/Severity: D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity: D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Scope/Severity: D
Ensure staff are vaccinated for COVID-19
Scope/Severity: C
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Scope/Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity: E
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Scope/Severity: K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Scope/Severity: E
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Scope/Severity: E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: E
Respond appropriately to all alleged violations.
Scope/Severity: K
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Scope/Severity: E
Report COVID19 data to residents and families.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Scope/Severity: D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity: E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity: D
Reasonably accommodate the needs and preferences of each resident.
Scope/Severity: B
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Scope/Severity: C
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Scope/Severity: D
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Scope/Severity: C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Scope/Severity: E
Prepare residents for a safe transfer or discharge from the nursing home.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
Scope/Severity: D
Ensure a qualified health professional conducts resident assessments.
Scope/Severity: F
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: F
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Scope/Severity: D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Scope/Severity: D
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Scope/Severity: E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: E
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Scope/Severity: D
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Scope/Severity: D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity: D
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Scope/Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: C
Provide and implement an infection prevention and control program.
Scope/Severity: D
Protect each resident from all abuse, physical punishment, and involuntary separation from others.
Scope/Severity: D
Reasonably accommodate the needs and preferences of each resident.
Scope/Severity: D
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: D
Provide care by qualified persons according to each resident's written plan of care.
Scope/Severity: D
Provide necessary care and services to maintain or improve the highest well being of each resident .
Scope/Severity: E
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Scope/Severity: E
Provide housekeeping and maintenance services.
Scope/Severity: D
Allow residents the right to participate in the planning or revision of care and treatment.
Scope/Severity: D
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
Scope/Severity: E
Store, cook, and serve food in a safe and clean way.
Scope/Severity: E
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Scope/Severity: D
Make sure that a working call system is available in each resident's room or bathroom and bathing area.
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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**